Healthcare Provider Details

I. General information

NPI: 1972923373
Provider Name (Legal Business Name): CIA GRONNEBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 BURREL AVE SE BOX 567
COOPERSTOWN ND
58425-0567
US

IV. Provider business mailing address

BOX 567 912 BURREL AVE SE
COOPERSTOWN ND
58425-0567
US

V. Phone/Fax

Practice location:
  • Phone: 701-797-2127
  • Fax: 701-797-2172
Mailing address:
  • Phone: 701-797-2127
  • Fax: 701-797-2172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3023
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: